- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $524.81 / $2,290.87
| Professional | | $371.54 | $524.81 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $125.89 / $354.81
| Professional | 26 | $85.11 | $125.89 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $223.87 / $380.19 / $758.58
| Professional | TC | $223.87 | $380.19 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Facility | 26 | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $1,698.24
| Professional | | $630.96 | $630.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $128.82 / $128.82 / $436.52
| Professional | 26 | $128.82 | $128.82 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $512.86 / $512.86 / $616.60
| Professional | TC | $512.86 | $512.86 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,584.89
| Professional | | $512.86 | $776.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $131.83 / $151.36 / $323.59
| Professional | 26 | $131.83 | $151.36 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $371.54 / $630.96 / $1,230.27
| Professional | TC | $371.54 | $630.96 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $1,698.24
| Professional | | $549.54 | $549.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $109.65 / $436.52
| Professional | 26 | $109.65 | $109.65 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | TC | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $851.14 / $1,348.96
| Professional | | $398.11 | $851.14 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $154.88 / $346.74
| Professional | 26 | $107.15 | $154.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $295.12 / $457.09 / $1,000.00
| Professional | TC | $295.12 | $457.09 | $1,000.00 |